Microbox white light PCNL simulator
PCNL simulators Dr Shankar Ram .Dr Aby Madan Dr Nazar M
1.Resident.2.Assistant Professor 3.Prof and HODDept of Urology .TD
MCH .Alleppy .Kerala
Small Models Sinha and Krishnamoorthy
Lezrek et al
Mobile model
Twin mobile model 2
2 way swithch LED model 4
Box model
AimTo create simplest PCNLpuncture trainer & understand
principles of punctureDesigning calyceal framework compatable for
white light .
Introduction White light fluroscopy PCNl simulation in BOX model
Portable \simple modelFirst micro model without radiation
Small Models Vegetable model sinha & Krishnamurthy et al
Chinese Glove model .Lazrek M et al
Construction
Design
Lids together Bottoms together
PCS from the side wall holes Can be rotated to change the calyx
direction
Resin sponge External
Making of Calyx
2. Straw bands straw1. OHP sheet
to be rolled up and banded 12
Opsite cup
Calyceal indentation and feeling of give away
Single bulb LED Keyboard light
020
Subtle difference in trajectory of conventional C arm x ray
source and microbox light source arising form same angles
39
Side movement Back and forth Movement(Mediolateral)
Interpretation of Shift in C arm Rotation according to XY angle
of calyx
Calyx Angle X Y
C armRotation ML CCShift
Craniopcaudal CCMediolateral rotatiopn MLSC-superio calyx IC
Inferior calyx Y axis is ureter Towards SC IC
Analysis
Puncture
Calyx Direction
Shortens Lengthen Directing Towards LED Away from LED
0 - 20 degreesNeedle Superficial Needle and calyx come closer
/OvershootsNeedle Deep Needle and Calyx separate apart /moves out
of calyx
10 degree caudal Needele .Superficial In image Needle slips out
of calyx towards LED light
Needle . Deep In image Needle slips out of calyx away from LED
light
Needle outside calyx
Puncture
Image J Analysis
Response Assessment Image (J) congruence - 97.3%SD0.7 (n =
20)Understanding Triangulation Demonstration of calyx indendation
Haptics Reasonable Overall comparision with c arm image
Conclusions Simple self make device will help in Understand the
principles involved in calyceal puncture Shoten learning curveThis
inexpensive,simple,portable model with reasonable haptics can be
used for dry lab training for PCNL puncture.
Experience factor Learnt all the passages Conditioning after
repeated trial and error
References References :
1. Maneesh Sinha, Venkatesh Krishnamoorthy. Use of a vegetable
model as a training tool for PCNL puncture . Ind . J Urol 2015
;31(2):156-1592. Lezrek M .Chinese shadows for initial learning of
calyx puncture without radiation exposure.Urology 84 (4 Supplement
1)s158 Oct 2014.
White light C Arm for PCNL simulation.
Models Animal model Cadaver model Virtual Reality simulators
Physical simulator model Simportal C Arm modelVirtual Fluroscopy
model
Transparent screen punctute model
Make Easy Save Easy Learn Easy Without Radiation
66
Key challenges unique characteristics Designing simple Fulcrum
for C arm Ennabling mediolateral and anteroposterior rotation Image
(shadow) capture similar to conventinal c armDesign appearance
similar to C arm Simple Home made prototype design
Construction
pic
BP apparatus stand Cycle rim Image ReceiverWEB cam + Paper drum
Calyceal system LED Short Focus Head lightFixed to Rim Plastic
Trolley PVC coupler Junction/ Fulcrum
Small PVC pipes in ball bearing arrangement within Coupler and
allows steady rotation of Cycle rim (C ARM )
Coupler and Fulcrum
Paper drum captures the shadow which is perceived by web cam on
the other side above
Thermocol based haptic model
Combined model
Ashish et al Transparent screen model
Triangulation
Superficial
Deep
0 - 30 degreesNeedle Superficial Needle and calyx come closer
/OvershootsNeedle Deep Needle and Calyx separate apart /moves out
of calyx
10 degree caudal Needele .Superficial In image Needle slips out
of calyx towards LED light
Needle . Deep In image Needle slips out of calyx away from LED
light
Interpretation of Shift in C arm Rotation according to XY angle
of calyx
Calyx Angle X Y
C armRotation ML CCShift
Craniopcaudal CCMediolateral rotatiopn MLSC-superio calyx IC
Inferior calyx Y axis is ureter Towards SC IC
Comparison of images with c arm
Image J analysis
Fixed reference points - ROIEdges ,cornersjunctions of calyx
Needle tipArea measured and analysed
Response Assessment Image (J) congruence 98.4%SD0.8 (n =
10)Understanding Triangulation Understnding orientation of calyx
Demonstration of calyx indendation Haptics Variable Gross Overall
comparision with c arm image almost same
Conclusion The simulators help acquiring basic knowledge and
skill to gain access to pelvicalyceal system andInterpretation of
shadows of calyx and its relationship with that of needle in two
different angles .The knowledge can be extrapolated in further
learning and practice
We hypothesise that these simulators Improve the Learning curve
of PCNL and eventually reduce the fluoroscopy time during training
as well as performing We recommend this for basic sructured PCNL
training for the urologist without radiation.
Limitations Needs multi center sample response assessment for
construct validation Dialatation Respiratory movements To be tried
in different calyceal anatomy
References 1.Chi-Fai Ng .Training in percutaneous
nephrolithotomy: The learning curve and options. Arab Journal of
Urology Volume 12, Issue 1, March 2014, Pages 54572.Triangulation
method in PCNL https://www.youtube.com/watch?v=ZsPsrtX5bIg .Dec 18,
2012 - Uploaded by Abdelazim Hussein3.Rick C. Slater,Michael Ost .
Percutaneous Stone Removal: New Approaches to Access and Imaging
.Current Urology Reports. 2015; 16(5)
EVOULUTION
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